Chapter 4 – Mishap Reporting and Investigating ... - NASA

Ames Health and Safety Procedures and Guidelines Last Revised: 09/26/2003 Redacted: 07/09/2004
Chapter 4 – Mishap Reporting and Investigating (REDACTED)
4.1 Introduction
4.1.1 Purpose
This chapter sets forth Ames policy for mishap reporting and investigating. The purpose of
mishap investigation is to determine the cause(s) so that proper corrective measures can be
taken and lessons learned from mishaps can be disseminated to other Ames organizations and
other NASA Centers to prevent similar mishaps.
4.1.2 Applicability
This chapter is applicable to all Ames employees, to all work conducted under the authority of
Ames, and to all equipment and property managed by Ames. For Ames contractors, it is
applicable through their contracts. Non-Ames and non-contractor personnel will follow the
provisions of this chapter while at Ames facilities.
4.1.3 Policy
All NASA reportable mishaps (see Definitions that follow) will be investigated and reported in
accordance with NASA directive NPG 8621.1.
4.2 Mishap Definitions
1. NASA Reportable Mishap: An event described in the following five paragraphs unless it
involves only off-site contractor personnel and contractor-owned equipment and property.
• Type A - A mishap that causes a death and/or damage to equipment or property equal
to or greater than $1,000,000. A mishap meeting these criteria that results in damage
to aircraft or space hardware (i.e., flight and ground support hardware) is included. This
definition also applies to a test failure, if the damage was unexpected or unanticipated,
or if the failure is likely to have significant program impact or visibility.
• Type B - A mishap that results in the permanent disability of one or more persons; or
hospitalization (for other than observation) of three or more persons; and/or damage to
equipment or property equal to or greater than $250,000 but less than $1,000,000.
Mishaps that result in damage to aircraft or space hardware and meets these criteria
are included, as is a test failure if the damage was unexpected or unanticipated.
• Type C - A mishap that results in damage to equipment or property equal to or greater
than $25,000 but less than $250,000; and/or causes occupational injury or illness that
results in a lost work day. A mishap that results in damage to aircraft or space
hardware and a test failure that meets this criterion are also included.
• Mission Failure - Any mishap (event) of such a serious nature that it prevents
accomplishment of most of the primary mission objectives. A mishap of such intrinsic
severity that, in the judgment of the Program Associate Administrator, in coordination
with the Associate Administrator for Safety and Mission Quality, it prevents the
achievement of primary mission objectives as described in the Mission Operations
Report or equivalent document.

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• Incident - A mishap of less than Type C injury, but more than first-aid severity
(recordable) and/or property damage equal to or greater than $1000 but less than
$25,000.
2. Close Call - An occurrence in which there is no injury or an injury of first-aid severity, no
significant equipment property damage (less than $1000), and no significant interruption of
productive work, but which possesses a high potential for any of the mishaps as defined in
paragraph 1.
3. Incident Commander - The individual responsible for the management of all operations at
the scene of an emergency incident.
4. Emergency Incident - A combination of circumstances that calls for immediate action in
response to an alarm.
5. Alarm - An audible or visible signal indicating an off-standard or abnormal condition.
6. Mishap - An unplanned, undesired event that results in personal injury or property damage.
4.3 References
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NPG 8715.3, NASA Safety Manual
NPD 8621.1 NASA Mishap, and Close Call Reporting, Investigating, and Recordkeeping
Policy
NPG 8621.1, NASA Procedures and Guidelines for Mishap Reporting, Investigating and
Recordkeeping
4.4 Non-emergency Mishaps
4.4.1 Occupational Injuries or Illness
Occupational injuries that are recordable under occupational injury reporting regulations are
reportable as mishaps. Any work-related or injury that requires medical attention greater than
first aid is recorded as an Incident. A work-related illness or injury that results in one or more
lost workdays after the day of the injury is reportable as a Type C mishap.
When an employee is injured, his/her supervisor is responsible for completing the unshaded
portions of a Mishap Report (NASA Form 1627) and submitting the first page to the Safety
Division. That first page of the mishap report, or the same information by other means, shall be
delivered to the Safety Division within 24 hours after learning of the mishap. Note: Usually a
representative of the Safety Division responds to the Ames Health Unit when a patient is being
seen for a recordable injury or illness, and gathers the pertinent data at that visit.
Upon completion of the supervisor's investigation of the injury, and within ten workdays, the
supervisor is responsible for completing the second part of the Form 1627 and submitting it to
the Safety Division.
Any incident that involves a bloodborne pathogen exposure always requires follow-up by the
Ames Health Unit.
The supervisor must consult with Ames Health & Safety Manual Chapter 32, Bloodborne
Pathogens Protection Plan, for guidance. The information on the form "Exposure Incident
Description" should be attached to the initial mishap report. The information on the form
"Follow-Up Evaluation of Exposure Incident" should be attached to the final mishap report.
4.4.2 Property Damage Mishaps
Mishaps for which no emergency actions are needed are handled in the same way as those
requiring emergency assistance. Personnel must follow applicable portions of the guidance in
section 4.5 that follows.

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4.5 Emergency Incidents that Require Help
4.5.1 Responsibilities of Employees
The most capable person at the scene of a mishap that requires emergency assistance acts as
the Incident Commander and ensures appropriate emergency response until relieved of this
duty by emergency response personnel, a representative of the Safety Division, senior
management, the Ames Fire Department, Ames Security Police, or other authorized personnel.
All personnel will support emergency response/mitigative actions to the best of their ability, as
directed by the Incident Commander.
1. Immediate Action
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Call 9-1-1 from Center phone, or REDACTED
(Dialing 911 from a non-Ames phone or cellular phone will result in your being connected
to an offsite 911 system and could delay the response.)
State that there is an emergency.
Describe location (building, room, area, etc.)
Identify yourself and your phone number.
Identify the type of emergency — medical, fire, security, toxic spill, etc.
Say how many people need help.
Describe the current situation.
Stay on the phone until you are released. Do not be the one to hang up first.
2. Follow-Up Action
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Provide assistance to injured persons.
If appropriate, take action to limit or prevent further injuries and damage. Follow facility
emergency procedures in order to reduce hazardous conditions, as appropriate.
Identify witnesses and victims.
Control access and secure the area to stop actions that could hamper or prevent
investigation of the mishap.
Notify division management in accordance with the division's emergency procedures.
Impound records, data, and similar information for future investigation.
Do not relinquish control of the accident scene until relieved by an emergency responder,
a responsible manager, or an Ames Police Officer.
3. Offsite Mishaps
Take appropriate emergency action as described above. Work with local officials and
emergency response personnel in accordance with emergency response plans. As soon as
conditions permit, call the Ames Security Dispatch at REDACTED and notify the emergency
operator of the mishap. Immediately report all work-related injuries/illnesses to your supervisor
and to the Ames Health Unit.
4.5.2 Responsibilities of Emergency Responders
In addition to any of the previously listed actions that still need to be taken, emergency
responders must preserve the accident scene, consistent with safety, for the impending
investigation. In addition, responders should maintain control of the scene until relieved by a
member of the Safety Division, another emergency responder, an assigned accident
investigator, or the Ames Police.
4.5.3 Responsibilities of Facility Managers
Directors or managers of facilities in which a mishap has occurred must cooperate with
emergency responders and investigators in the control of the accident scene, the identification
and interview of witnesses, and where necessary, the impoundment of records and collection
and analysis of recorded information to facilitate the investigation.

Chapter 4 – Mishap Reporting and Investigating (REDACTED) Page 4 of 7
4.5.4 Responsibilities of Ames Security Dispatch
Immediately after requesting the appropriate emergency response, the Ames Security Dispatch
will notify the cognizant supervisor, assigned Safety Division personnel, and other appropriate
personnel (per the emergency call list).
4.5.5 Responsibilities of Contractors
Contractors shall investigate all contractor mishaps that do not involve NASA property or civil
servants. A copy of the report shall be forwarded to the Safety Division within 10 days unless
approved otherwise by the Safety Division. Report injuries electronically at http://Q on NASA
Form 1627, Mishap Incident Report.
If NASA and a contractor or resident agency conduct separate but parallel investigations of the
same mishap, the two investigators or boards are encouraged to share fact-finding, data, and
evidence. However, when it comes to deliberation of conclusions and cause(s), each
investigator or board shall act independently of the other. No parallel investigation will be
allowed to impede a NASA investigation. Contractors will cc a copy of ARC 15, Contractor
Monthly Accident Report to the Safety Division monthly.
4.6 Mishap Investigation & Reporting
4.6.1 The Investigator
If no emergency responders are on the scene, the responsible supervisor or assigned safety
representative initiates an investigation. If an emergency response has occurred, the
emergency responder maintains control of the mishap scene and may proceed with the
investigation until relieved by the Safety Division representative, or a specifically designated
Mishap Investigation Board or Investigator.
Note: The Ames Center Director is the appointing authority for the Type B mishaps and for
Type A mishaps when so designated.
An onsite investigator has the authority to take all appropriate measures to ensure that a proper,
complete, and timely investigation is completed.
The investigator will complete the following as appropriate:
1. Safeguard the site of the mishap until all appropriate physical evidence can be obtained
and preserved. Security provides assistance, as directed by the investigator.
2. Identify witnesses and victims and take their statements.
3. Ensure that appropriate photographs of the mishap site are obtained. An Ames
photographer, under the direction of the investigator, normally does this.
4. Complete and submit an initial report of the mishap on a NASA Form 1627. Initial reports
must be submitted to the Safety Division within 24 hours of the mishap.
5. Complete a formal investigation report (Type A or B) in accordance with guidance in NPG
8621.1, and submit it to the appointing authority.
6. Complete a formal investigation report (Type C, when requested) in accordance with
guidance provided by the appointing authority.
The membership of a formal mishap investigation board (A or B) does not include anyone from
the organization responsible for the mishap, unless required for expertise.
The organization responsible for the mishap is responsible for the cost of the investigation.
All mishap reports, both Forms 1627 and formal reports, shall include the investigator's best
estimate of the dollar value of damage resulting from the mishap.

Chapter 4 – Mishap Reporting and Investigating (REDACTED) Page 5 of 7
4.6.2 Safety Office
1. A Safety Office on-call representative responds to each mishap as necessary to be a focus
of Safety Office support and provide immediate technical expertise as appropriate. The
Safety Office representative shall:
Determine the mishap type (see definitions in section 4.2 of this chapter or NMI 8621.1,
"Mishap Reporting and Investigating"). If a Type A or B mishap, the Safety Division notifies
the Deputy Director or Director, the Public Information Officer, and the NASA Safety
Division at Headquarters. The Safety Division submits a Telephone Initial Mishap Report
(NASA Form 1627A) within 24 hours of the mishap (except as stated below).
For Type A mishaps involving a fatality, or Type B mishaps involving the hospitalization of
three or more NASA employees (or a combination of three NASA and non-NASA
personnel), notification to NASA Headquarters Safety Division must be made within a few
hours to support Headquarters notification to Federal OSHA within 8 hours.
The following telephone numbers are available for these calls:
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M-F, 8 am to 5 pm EST — REDACTED (Safety Division Chief Office)
M-F, 5 pm to 8 pm EST — REDACTED (Safety Division Chief Mobile)
M-F, back-up number — REDACTED (Safety Program Manager)
Off-shift — REDACTED
For events involving Weapons of Mass Destruction anytime — REDACTED
2. Ensure that reporting requirements of this chapter are met and that a proper investigation is
conducted in accordance with applicable regulations and standards.
3. Verify that appropriate measures have been taken, or are taken, to secure the mishap
scene to protect personnel from the hazards and to preserve evidence for the investigation.
4. Assure that appropriate defensive and offensive measures have been taken, or are taken,
to protect life/health, the environment, and property.
5. Notify appropriate Organizational Director(s).
6. Input information from mishap reports into the Incident Reporting and Information System
(IRIS), the NASA agency-wide mishap reporting database. This database is hosted by
Headquarters and provides a means for exchanging mishap information with the other
NASA centers. The information is used to analyze trends and disseminate lessons-learned
information for prevention of future mishaps.
The Safety Office typically provides the following additional support to investigation boards and
committees:
1. System safety support
2. Direct consulting services
3. Tracking of corrective actions
4. Trending and analysis of mishap causes
5. Advise and consult with the Center Director on staffing of investigation boards
The Safety Office also distributes a summary of each major mishap report, including findings
and recommendations, to all Ames staff to whom the lessons could be of value.

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4.7 Appendix A: Mishap Responsibilities and Timeline
Action By Whom When
Report to Ames Health Unit Employee As soon as able after a
nonemergency illness or
injury
Dial 9-1-1/Ames Security
Dispatch for immediate
response
Notify Ames Health Unit (if
medical emergency)
Emergency treatment
Notify Safety Office &
supervisor (Type A, B, & C
mishaps)
Assume control of mishap
scene (if applicable)
Notify Director and HQ /
Code QS (Type A, B, and
Mission Failure mishaps)
Notify Public Affairs Director
(if applicable)
Initiate conference for
investigation board
appointment (Type A & B, &
sometimes C)
Send board appointment
letters (if applicable)
Complete a Telephonic
Mishap Report, NASA Form
1627A (if HQ notified)
Completed NASA Form 1627
(unshaded sections) and
send to Safety Office
Completed
Compensation/Insurance
Forms CA-1 or CA-2
(Federal employees)
Enter data into NASA
database
Complete CA-16, sheet 1
(Federal employees)
Board convenes (if
applicable)
Send interim (2 week) status
report to Appointing Official
(if applicable)
Complete NASA Form 1627,
follow-up report
Supervisor or eyewitness to
an emergency mishap
Ames Security Dispatch
Health Unit physician,
ambulance crew,
paramedics
Ames Security Dispatch
and/or Ames Health Unit
Cognizant supervisor,
designated representative,
emergency responder
Safety Office representative
Center Director (or, as
delegated, Safety Office)
Appointing Official (HQ if
Type A; Center Director with
HQ concurrence if Type B)
Appointing official
Safety Office representative
Supervisor
Supervisor
Safety Office representative
Ames Heath Unit
Board chairperson
Board chairperson
Immediately
Immediately
Immediately
Immediately
ASAP
ASAP
ASAP to 3 days
ASAP to 3 days
ASAP to 3 days
+1 day
+1 day
+1 day
+1 to 2 days after receipt
+2 days
+3 days
+3 to 5 days, then every two
weeks
Supervisor
+10 days, or on employee's
return to work
Report to Ames Health Unit Employee On employee's return to work

Chapter 4 – Mishap Reporting and Investigating (REDACTED) Page 7 of 7
Action By Whom When
Complete Form ARC 215 Ames Health Unit physician On employee's return to work
Medical Disposition
Verify corrective actions
implemented (if no board
investigation)
Safety Office representative Prior to close-out
Note: All remaining steps are applicable only if mishaps have a board investigation.
Action By Whom When
Send undated board report Board Chairperson
+60 days
(all volumes) to Appointing
Official
Accept or reject report Appointing Official +80 days
Develop formal Corrective Appointing Official/board +80 days
Action Plan
Forward 15 copies of report Appointing Official
+80 days
and CA Plan to Director/QS
Concur and date report Director/QS +105 days
Dismiss board, publish and
distribute report
Enter appropriate final
mishap information into
NASA Incident Reporting
Information System (IRIS)
database Safety
Appointing Official
Office representative
+145 days
+160 days